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BackTable / ENT / Article
Evaluating Success in Eustachian Tube Balloon Dilation: Outcomes & Complications
Iman Iqbal • Updated May 28, 2024 • 423 hits
Balloon dilation offers an effective, minimally invasive solution to improve eustachian tube function. Successful outcomes and the prevention of complications hinge on surgical technique and strict adherence to post-operative care guidelines.
Otolaryngologist Dr. Dennis Poe walks through outcome measures for eustachian tube balloon dilation, including the normalization of tympanogram readings and the patient's ability to perform a modified Valsalva maneuver. He further describes how to avoid severe complications of the procedure, like subcutaneous emphysema, by maintaining a direct view of the eustachian tube lumen and utilizing an angled endoscope. Finally, he emphasizes the post-operative instructions that are necessary for patients to follow for optimal outcomes and improved patient comfort.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• An important outcome measure in evaluating eustachian tube dysfunction is achieving tympanogram normalization.
• Assessing a patient's ability to perform a modified Valsalva maneuver is necessary, as it indicates whether further management is required.
• Subcutaneous emphysema is the most common complication reported with eustachian tube balloon dilation, often resulting from inadvertent laceration of the membranous wall during the procedure.
• Utilizing an angled endoscope facilitates visualization of both walls, minimizing the likelihood of false passages or injuries.
• Safety markers, such as a yellow mark at 31 millimeters, should remain visible during insertion to prevent over-insertion into the eustachian tube.
• Following pediatric eustachian tube balloon dilation, patients should refrain from blowing their nose or performing a modified Valsalva maneuver during the initial week.
• Patients can anticipate a gradual decrease in swelling over four to six weeks, with noticeable symptom improvement typically within the same timeframe.
Table of Contents
(1) Assessing Outcomes After Eustachian Tube Balloon Dilation
(2) Avoiding Risks and Complications of Eustachian Tube Balloon Dilation
(3) Post-Operative Care After Eustachian Tube Balloon Dilation
Assessing Outcomes After Eustachian Tube Balloon Dilation
An important outcome of eustachian tube balloon dilation is tympanogram normalization, specifically transitioning from Type C or B to Type A. In addition to this, it is necessary to assess a patient's ability to perform a modified valsalva maneuver, as this indicates need for further management. Dr. Poe explains that the maneuver should be done gently to avoid adverse effects: gentle pressure with nose and mouth closed, accompanied by swallowing. For children that are unable to perform the maneuver, alternative methods such as Otovent balloons or the Eustachi device may be considered. Additional outcome measures include clinical examination, ability to insufflate, audiogram results, and the patient’s own subjective feedback.
[Dr. Ashley Agan]
Looking at your outcomes, you're hoping to have normalization of that tympanogram, moving from either a type C or B to a Type A. Do you also measure a patient's ability to perform Valsalva or Modified Valsalva, is that one of your outcome measures as well?
[Dr. Dennie Poe]
Yes, it is. All the kids we take to, even when I see them in the office and I'm just evaluating them right from the beginning, I try to teach all of them a modified Valsalva. Not holding your nose and blowing hard because people have blown out and destroyed their sensorineural hearing and gotten vertigo from that. A modified Valsalva, nose and mouth closed, gently blown, only gently, so there's just a little positive pressure, and they swallow hard at the same time.
…
Now if they're just too young to coordinate that or they just can't get it, then we have them do these Otovent balloons, which are actually pretty good, and that's recommended in the CPGs as well, or that eustachi device, a little air pump that goes up to your nose.
…
[Dr. Ashley Agan]
Okay, great. Any other outcomes that you're looking for, tympanograms, ability to Valsalva, or Modified Valsalva?
[Dr. Dennie Poe]
Yes, the clinical exam, ability to insufflate, the audiogram as well, I want to see their conductive hearing loss has gotten better and I want to see that modified Valsalva. All of those, yes.
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Avoiding Risks and Complications of Eustachian Tube Balloon Dilation
The most commonly reported complication of eustachian tube balloon dilation is subcutaneous emphysema, often resulting from inadvertent laceration of the membranous wall during the procedure. To mitigate this risk, Dr. Poe emphasizes the importance of maintaining a direct view down the eustachian tube lumen to ensure visualization of both walls, akin to examining both vocal cords during laryngoscopy. Utilizing an angled endoscope facilitates this visualization, minimizing the likelihood of false passages or injuries.
Additionally, the flexible nature and safety features of the balloon device serve to prevent inadvertent tissue damage and guide safe insertion. It is equipped with a soft, round, 2-millimeter diameter tip designed to navigate the curvatures of the eustachian tube, including its initial medial curve and its path behind the adenoid. The flexibility of the balloon aids in negotiating these turns, while the ball tip helps push aside the mucosa as it advances. There are also safety markers, such as a yellow mark at 31 millimeters, which should remain visible during insertion to prevent over-insertion into the eustachian tube.
[Dr. Ashley Agan]
Can you talk about other risks and complications that you've seen and how to avoid them?
[Dr. Dennie Poe]
Yes, there was actually a paper that just came out recently looking at the MAUDE, M-A-U-D-E. This is the self-reported complications to the FDA with these devices. The most common one was subcutaneous emphysema. That is a laceration or false passage through the membranous wall. The membranous wall is only a few cells thick.
…
The only way to avoid that is to have a direct view down the lumen of the eustachian tube. This is why I always recommend that you've got to be able to see both walls. With your clinical exam, you want to see both walls of the valve, not just one.
…
What commonly happens is the surgeons are confident, I can see everything I need to with a zero degree [scope]. They don't see the membranous wall, but they say, "Well, I've got the torus there." If you angle off of the torus, it actually takes you through the membranous wall. That's how it happens. In fact, there was a carotid injury, which I'm sad to say. This was in one of the rail-based devices where there's a bendable rail and the balloon slides up on that. You put the rail up into the lumen and you slide the balloon up there to do your balloon dilation. I didn't discuss it in the article, but we've duplicated this in the lab years ago.
We knew this could happen with anything rigid. That's why we don't put rigid things in the eustachian tube. If you angle off the torus, what probably happened in that case was the rail went right through the membranous wall. That takes you in a vector straight toward the carotid.
…
The balloon has safety devices for all of this. It's got a soft, round, 2-millimeter diameter tip that if you don't push it in fast and you watch it go up the membranous wall, now the eustachian tube curves initially, medially, it actually dives behind the adenoid a little bit, and then it curves off toward the ear. A lot of surgeons don't realize that because they haven't looked up that far. The balloon is flexible for just that reason, so it's going to navigate that turn, and it's got that ball tip so that it'll push the mucosa aside as you get up out of sight. As a surgeon, you're going to set it along the membranous wall, tangential to it so you won't penetrate it, and then as it disappears out of sight, it's going to just curve around.
The cartilage becomes increasingly circumferential, and so it'll just guide along there. The other safety features are, so you're normally going to feel the isthmus when that ball tip contacts it, and there's a little mark at 31 millimeters. This yellow mark should never disappear into the lumen because the average eustachian tube cartilaginous length is 25mm. It should normally be sticking out about a half a centimeter from the orifice. In the smaller kids, maybe stick out even more than that, maybe up to a centimeter in the smallest 8-year-olds. You want to see that yellow mark is not going to go into the orifice, you're going to feel that little ball tip touch the isthmus, and so that's how you do it.
You insert it under direct view, typically you need an angled endoscope, but not necessarily. If you can see both walls, you're fine. If you can see both walls with a zero degree, you're fine, but if you can't, get out the angled scope. That's how you avoid this problem of air emphysema.
Post-Operative Care After Eustachian Tube Balloon Dilation
Following pediatric eustachian tube balloon dilation, adherence to post-operative instructions is pivotal for optimal outcomes and patient comfort. Patients should refrain from blowing their nose or performing a modified Valsalva maneuver during the initial week. Older children and adults can commence modified Valsalva after a week to facilitate ear aeration. Temporary soreness in the nasopharynx or ear is expected for a day or two. Humidification of the nose is recommended for comfort. Patients can anticipate a gradual decrease in swelling over four to six weeks, with noticeable symptom improvement typically within the same timeframe.
[Dr. Ashley Agan]
With your post-op instructions, other than not blowing their nose or doing a modified Valsalva in the first week, any other instructions that you give them? In my experience with adults, there's not a ton of post-operative pain to treat. If they're getting an adenoidectomy, they're going to probably need some Tylenol Motrin, but any other post-op instructions that are specifically related to the balloon portion?
[Dr. Dennie Poe]
Not really. It's extremely well tolerated. I warn the parents they're going to complain more of a sore throat from their endotracheal intubation than they'll complain about their ear or the back of their nose. It's very, very well tolerated. If they have any soreness in the nasopharynx or ear, it's really temporary, a day or two. We talk about keeping the nose humidified if needed for comfort measures, but no, it's really the modified Valsalva nose blow, that's the main post-op instruction. Oh, and then after, older kids, adults, after a week, I do encourage them to do the modified valsalva. Let's get that ear aerated as quickly as possible.
The swelling from the balloon is going to decrease over about four to six weeks after the procedure. You do want to try to get that eustachian tube aerated. We wait a week, and then I start having them do their Otovent balloon or the modified valsavas if they can coordinate that.
Podcast Contributors
Dr. Dennis Poe
Dr. Dennis Poe is an Associate in the Department of Otolaryngology and Communication Enhancement at Boston Children's Hospital, specializing in heotology/neurotology and skull base surgery.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, February 20). Ep. 159 – Eustachian Tube Dilation In The Pediatric Population [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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